Travel Notification Form
*Indicates a required field.
MEMBER INFORMATION ("FROM" ACCOUNT):
Member Account Number
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Credit Card Number
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Card Type
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Debit Card
Credit Card
First Name
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Middle Initial
Last Name
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Social Security Number
Phone Number
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Email Address
Country Traveling to
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Travel Start Date (MM-DD-YY)
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Travel End Date (MM-DD-YY)
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Comments
ELECTRONIC FORM SUBMISSION AGREEMENT
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By submitting this form I am verifying the following:
1. The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the transaction requested above.
2. I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union.
3. I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval.
4. Entering my first and last name in the Electronic Signature field stands as the equivalent of a handwritten signature. Therefore, by entering fraudulent or false information, you are commiting forgeryy and are subject to the equivalent applicable laws and penal action.
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Yes, I agree to the terms and conditions of submitting this form Electronically as outlined in the guidelines above.
Electronic Signature (please print your first and last name)
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Date
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